DPW FORM 120 (Rev - Hawaii Department of Transportation



DPW FORM 120 (Rev. 6/99)

| STATE OF HAWAII |

|DEPARTMENT OF ACCOUNTING AND GENERAL SERVICES |

| QUESTIONNAIRE FOR ARCHITECTS, ENGINEERS AND OTHER PROFESSIONAL SERVICES |

|QUESTIONNAIRE FOR: (LIST DISCIPLINE) |OTHER QUESTIONNAIRES SUBMITTED: (LIST DISCIPLINES) |DATE |

| | | |

|FIRM NAME | ESTABLISHED |TYPE OF ORGANIZATION (Underline) |

| |YEAR STATE | |

| | |INDIVIDUAL PARTNERSHIP CORPORATION JOINT VENTURE OTHER |

|BUSINESS ADDRESS, TELEPHONE & FAX NO. OF HAWAII OFFICE |AGE OF FIRM |FEDERAL ID NO. |YEARS ESTABLISHED IN |

| | | |HAWAII |

|PRINCIPALS OF FIRM: (NAMES) |ASSOCIATE MEMBERS OF FIRM: (NAMES) |

| | |

| | |

|PRESENT BRANCH OFFICE(s): (ADDRESS, TELEPHONE & FAX NO.) |PERSON IN CHARGE: (NAMES) |

| | |

| |

|NUMBER OF PERSONNEL IN YOUR PRESENT ORGANIZATION |

|LOCATED AT |PRINCIPALS & KEY | OTHER PERSONNEL | TOTAL |

| |PERSONNEL | | |

| |Architect |Engineer |Others |Architect |

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DPW FORM 120 (Rev. 6/99)

| PERSONAL HISTORY STATEMENT OF PRINCIPALS AND ASSOCIATES WITHIN YOUR FIRM |

|NAME |RESIDENT OF |NAME |RESIDENT |

|TITLE |TITLE |

|YEARS OF EXPERIENCE |AS PRINCIPAL |AS PRINCIPAL |OTHER THAN |YEARS OF |AS PRINCIPAL |AS PRINCIPAL IN OTHER |OTHER THAN PRINCIPAL |

| |IN THIS FIRM |IN OTHER FIRMS |PRINCIPAL |EXPERIENCE |IN THIS FIRM |FIRMS | |

|EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |

| | |

|MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS |MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS |

| | |

|REGISTRATION (TYPE, YEAR, STATE) |REGISTRATION (TYPE, YEAR, STATE) |

| | |

|NAME |RESIDENT OF |NAME |RESIDENT OF |

|TITLE |TITLE |

|YEARS OF |AS PRINCIPAL |AS PRINCIPAL IN |OTHER THAN PRINCIPAL |YEARS OF EXPERIENCE |AS PRINCIPAL |AS PRINCIPAL IN OTHER |OTHER THAN PRINCIPAL |

|EXPERIENCE |IN THIS FIRM |OTHER FIRMS | | |IN THIS FIRM |FIRMS | |

|EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |

| | |

|MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS |MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS |

| | |

|REGISTRATION (TYPE, YEAR, STATE) |REGISTRATION (TYPE, YEAR, STATE) |

| | |

Page 2 of 9

DPW Form 120 (Rev. 6/99)

| PERSONAL HISTORY STATEMENT OF TECHNICAL PERSONNEL WITHIN YOUR FIRM |

|NAME |STATUS (Underline) |NAME |STATUS (Underline) |

| |Full-Time Part-Time | |Full-Time Part-Time |

|TITLE OR POSITION |YEARS OF EXPERIENCE |TITLE OR POSITION |YEARS OF EXPERIENCE |

| | | | |

|WITH THIS FIRM |WITH LAST FIRM |WITH OTHER FIRMS |WITH THIS FIRM |WITH LAST FIRM |WITH OTHER FIRMS |

| |(NAME & NO. OF YEARS) | | |(NAME & NO. OF YEARS) | |

|EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |

|REGISTRATION (TYPE, YEAR, STATE) |REGISTRATION (TYPE, YEAR, STATE) |

|NAME |STATUS (Underline) |NAME |STATUS (Underline) |

| |Full-Time Part-Time | |Full-Time Part-Time |

|TITLE OR POSITION |YEARS OF EXPERIENCE |TITLE OR POSITION |YEARS OF EXPERIENCE |

|WITH THIS FIRM |WITH LAST FIRM |WITH OTHER FIRMS |WITH THIS FIRM |WITH LAST FIRM |WITH OTHER FIRMS |

| |(NAME & NO. OF YEARS) | | |(NAME & NO. OF YEARS) | |

|EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |

|REGISTRATION (TYPE, YEAR, STATE) |REGISTRATION (TYPE, YEAR, STATE) |

|NAME |STATUS (Underline) |NAME |STATUS (Underline) |

| |Full-Time Part-Time | |Full-Time Part-Time |

|TITLE OR POSITION |YEARS OF EXPERIENCE |TITLE OR POSITION |YEARS OF EXPERIENCE |

| | | | |

|WITH THIS FIRM |WITH LAST FIRM |WITH OTHER FIRMS |WITH THIS FIRM |WITH LAST FIRM |WITH OTHER FIRMS |

| |(NAME & NO. OF YEARS) | | |(NAME & NO. OF YEARS) | |

|EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |EDUCATION (COLLEGE, DEGREE, YEAR, SPECIALIZATION) |

|REGISTRATION (TYPE, YEAR, STATE) |REGISTRATION (TYPE, YEAR, STATE) |

Page 3 of 9

DPW FORM 120 (Rev. 6/99)

OUTSIDE ASSOCIATES AND CONSULTANTS USUALLY EMPLOYED

| DISCIPLINE | NAME OF FIRM OR INDIVIDUAL | | DISCIPLINE | NAME OF FIRM OR INDIVIDUAL |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

ERRORS AND OMISSIONS INSURANCE

| DOES YOUR FIRM HAVE ERRORS & OMISSION (E&O) INSURANCE? (Underline) | AMOUNT OF COVERAGE | AMOUNT OF DEDUCTIBLE |

| |PER CLAIM | |

| YES | NO | PROJECT INSURANCE |$ |$ |

Submit proof of insurance or insurability from your insurance carrier with this form.

Page 4 of 9

DPW FORM 120 Rev. 6/99)

SUMMARY OF YOUR FIRM’S COMPLETED AND PRESENT PROJECTS DURING THE LAST TEN YEARS

AS A PRIME A/E CONSULTANT

|TOTAL NUMBER OF COMPLETED PROJECTS | |

|TOTAL ESTIMATED CONSTRUCTION COST OF COMPLETED PROJECTS |$ |

|TOTAL NUMBER OF PRESENT PROJECTS | |

|TOTAL ESTIMATED CONSTRUCTION COST OF PRESENT PROJECTS |$ |

AS AN ASSOCIATE WITH OTHER A/E CONSULTANTS

|TOTAL NUMBER OF COMPLETED PROJECTS | |

|TOTAL ESTIMATED CONSTRUCTION COST OF COMPLETED PROJECTS (ONLY THE PORTION OF WORK FOR WHICH YOUR FIRM WAS RESPONSIBLE) |$ |

|TOTAL NUMBER OF PRESENT PROJECTS | |

|TOTAL ESTIMATED CONSTRUCTION COST OF PRESENT PROJECTS (ONLY THE PORTION OF WORK FOR WHICH YOUR FIRM IS RESPONSIBLE) |$ |

CLASS OF WORK AND PROJECT TYPE SPECIALIZATION

| TYPE OF PROJECT | TOTAL NO. OF COMPLETED | TOTAL ESTIMATED | TOTAL ESTIMATED PROJECT SIZE (G.S.F.) |

| |PROJECTS |CONSTRUCTION COST | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Categorize your firm’s class for work during the last ten years by project type. Examples of project types include Educational, Commercial, Industrial, Residential, Health Care, Correctional and Judicial Facilities. Work may also be categorized as planning, civil sitework, renovation/alteration, architectural barrier removal, fire alarm system, etc.

Page 5 of 9

DPW FORM 120 (Rev. 6/99)

PRESENT/COMPLETED PROJECTS IN WHICH YOUR FIRM IS/WAS DESIGNATED THE PRIME CONSULTANT (BY TYPE)

(LIST A MAXIMUM OF 10 PROJECTS FOR EACH DISCIPLINE/TYPE OF WORK BEING APPLIED FOR. LIST PROJECTS THAT REFLECT YOUR ABILITY TO PROVIDE QUALITY

WORK FOR YOUR REQUESTED PROJECTS.)

|TYPE: |

| YEAR | NAME AND LOCATION | NAME OF LEAD | NAME, ADDRESS, PHONE & FAX NO. | ESTIMATED | DURATION FOR | % | |

| |OF THE PROJECT |DESIGNER |OF THE OWNER |CONST. COST |DESIGN |COMPLETED | |

| | | | |($) |(MONTHS) | | |

Page 6 of 9

DPW FORM 120 (Rev. 6/99)

PRESENT/COMPLETED PROJECTS THAT YOUR FIRM IS/WAS ASSOCIATED WITH OTHERS (BY TYPE)

(LIST A MAXIMUM OF 10 PROJECTS FOR EACH DISCIPLINE/TYPE OF WORK BEING APPLIED FOR. LIST PROJECTS THAT REFLECT YOUR ABILITY TO PROVIDE QUALITY

WORK FOR YOUR REQUESTED PROJECTS.)

|TYPE: |

|YEAR |

| |

|As of this date ____________________________ the foregoing is a true statement of facts. |

|NAME OF FIRM OR INDIVIDUAL SUBMITTING QUESTIONNAIRE |TYPE NAME AND TITLE OF PERSON SIGNING |SIGNATURE |

| | | |

|NOTE: It is to a firm’s advantage to maintain its experience record on a current basis. This may be accomplished by periodically forwarding current data to DAGS. |

Page 8 of 9

DPW FORM 120 SUPPLEMENT 1 (Rev. 6/99)

PRINCIPALS ONLY - ADDITIONAL INFORMATION

|NAME |TITLE AND POSITION |YEARS WITH FIRM |

|MAJOR RESPONSIBILITIES WITH THIS FIRM |

| |

| |

|PRIOR EMPLOYMENT |

|(START WITH LATEST EMPLOYMENT PRIOR TO JOINING THIS FIRM AND PROVIDE SIMILAR INFORMATION FOR EACH SEPARATE |

|EMPLOYMENT OR MAJOR CHANGES IN DUTIES WITH THE SAME EMPLOYER.) |

|FIRM: | DATE |FIRM: | DATE |

| |FROM: TO: | |FROM: TO: |

| | | | | | |

|ADDRESS: |ADDRESS: |

|JOB TITLE: |JOB TITLE: |

|SUPERVISOR’S NAME AND TITLE: |SUPERVISOR’S NAME AND TITLE: |

|MAJOR DUTIES: |MAJOR DUTIES: |

| | |

| |

|FIRM: | DATE |FIRM: | DATE |

| |FROM: TO: | |FROM: TO: |

| | | | | | |

|ADDRESS: |ADDRESS: |

|JOB TITLE: |JOB TITLE: |

|SUPERVISOR’S NAME AND TITLE: |SUPERVISOR’S NAME AND TITLE: |

|MAJOR DUTIES: |MAJOR DUTIES: |

| | |

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